Is endoanal, introital or transperineal ultrasound diagnosis of sphincter defects more strongly associated with anal incontinence?

Functional Assessment of Anal Sphincter with Transperineal Ultrasound and Its Relationship to Anal Continence

BACKGROUND/OBJECTIVES

Anal incontinence is linked to pelvic floor dysfunction. Diagnosis involves assessing both the function and structure of the anorectal unit. Although transperineal ultrasound has gained attention as a less invasive option, its effectiveness as a diagnostic tool for evaluating the relationship between structure and function is still debated. This study aimed to explore the relationship between quantitative measurements of anal sphincter and pelvic floor structures as well as the subjective symptoms and objective assessments of sphincter function regarding anal incontinence.

METHODS

50 women with pelvic floor dysfunction were recruited for the study. The severity of anal incontinence was assessed using the CACP score. Ultrasound imaging was employed to measure anal sphincter area, while sphincter pressures were evaluated through manometry. The relationships between variables were analyzed using Pearson's and Spearman's correlation tests.

RESULTS

The mean anal sphincter area was 5.51 cm2 at rest and 4.06 cm2 during maximal contraction. Resting anal sphincter pressure had an average of 46.29 mmHg, and contraction pressure averaged 103.25 mmHg. No significant correlation was found between the anal sphincter area and pressure at rest (r = 0.018) or during contraction (r = -0.210). However, a moderate correlation was observed between the change in sphincter pressure and area during contraction (r = 0.312). The CACP score showed no significant correlation with the sphincter area at rest (r = -0.084) but was weakly correlated during contraction (r = -0.270).

CONCLUSIONS

Conventional diagnostic tools for evaluating anal incontinence can be uncomfortable and are not always readily available. Perineal sonography presents a promising, less invasive alternative for dynamic assessment of the anal sphincter.

Three-Dimensional Transperineal Ultrasound Guiding Early Secondary Repair of Obstetric Anal Sphincter Injury in an Incontinent Patient without Suture Dehiscence

We present the case of a 36-year-old primigravida who gave birth to a 3200 g baby by vacuum-assisted (Kiwi OmniCup™) operative vaginal delivery with mediolateral episiotomy. A "y"-shaped perineal tear with a grade IIIC obstetric anal sphincter injury (OASI) was diagnosed and repaired. Two days after delivery, in the absence of suture dehiscence, she started experiencing complete anal incontinence. A decision was made in association with a proctologic surgeon for an early secondary repair. Before surgery, a Three-dimensional transperineal ultrasound (TPUS) was performed. The exam revealed a major defect of the external anal sphincter at the 11 o'clock position. This allowed for the reopening of only a circumscribed area of the perineal suture and repair of the sphincters using the end-to-end technique. The symptoms regressed completely, and follow-up TPUS demonstrated the gradual wound healing process. Anal incontinence, secondary to obstetric anal sphincter injury (OASI), has a severe negative impact on women's quality of life. TPUS is an effective method to detect sphincter defects and monitor the healing process. This report investigates the feasibility of identifying the sphincter tear in an incontinent puerperal patient without suture dehiscence in order to target early secondary repair while minimizing its extent. TPUS has proven a safe and effective tool to guide early secondary repair of symptomatic OASI complications while minimizing the invasiveness of the procedure. Multidisciplinary management is crucial to ensure the adequate standard of care.

Assessing Obstetric Anal Sphincter Injuries: A Comparison of Exoanal and Endoanal Ultrasound

OBJECTIVES

To explore the differences in assessing obstetric anal sphincter injuries (OASI) between transperineal ultrasound (TPUS) and endoanal ultrasound (EAUS) and test relationships between ultrasound findings and anal incontinence (AI) symptoms.

METHODS

A group of 196 women with a history of vaginal delivery was recruited. OASI was detected in a set of 5 slices by EAUS and 8 slices by TPUS. OASI grading was performed on TPUS rules and EAUS rules. A "significant sphincter defect" was diagnosed by TPUS and EAUS using "2/3 rules." Symptoms of AI were determined using the St Mark's Incontinence Score (SMIS). Ultrasound findings were compared between the two methods and correlated with symptoms.

RESULTS

Of 196 women, 29 (14.8%) suffered from AI with a mean SMIS of 12.1 ± 4.5, and 70 (35.7%) women with a mean age of 57 years had suspected OASI on imaging. Twenty-one (10.7%) "significant defects" were diagnosed by TPUS and 24 (12.2%) by EAUS. OASI Grades on TPUS had good agreement with EAUS rules (k = 0.70, P < .001). Logistic regression analysis showed that OASI Grade on imaging and "significant sphincter defects" seen on both forms of imaging were associated with AI symptoms. The odds ratio was 46 and 38 for "significant defects" on TPUS and EAUS, and 14 and 7 for OASI 3b+ on TPUS and EAUS in predicting AI, respectively.

CONCLUSIONS

"Significant defects" diagnosed by EAUS or TPUS and OASI Grade 3b+ predict AI symptoms. The diagnostic performance of endoanal and exoanal ultrasound (EAUS and TPUS) appear to be very similar.

The role of anal manometry in the follow-up of women with obstetric anal sphincter injuries (OASI)

INTRODUCTION AND HYPOTHESIS

Mode of birth (MOB) following OASI is determined by choice, symptoms and anorectal study results in asymptomatic women. Endoanal ultrasound (EAUS) is the gold-standard imaging modality. EAUS use in MOB counselling is supported by strong evidence. Less is understood about how anal manometry (AM) influences MOB counselling.

METHODS

A retrospective observational study was conducted from 2007 to 2020. Women underwent symptom assessment using validated ePAQ and St Mark's incontinence score (SMIS). Anorectal studies using EAUS and AM were performed. The case group was the normal ultrasound group and the control group was the abnormal ultrasound group. Both groups were compared with normal and abnormal AM result groups.

RESULTS

A total of 1348 women were included over 13 years. Among these, 454 women were symptomatic, 894 were asymptomatic; 274 (31%) asymptomatic women had isolated abnormal AM results, 313 (35%) had two abnormal anorectal results and 221 (24.7%) had normal anorectal results. Eighty-six asymptomatic women (10.4%) had isolated abnormal EAUS results, 138 (30.4%) symptomatic women had isolated abnormal AM, 221 (48.7%) had two abnormal anorectal results and 57 (12.6%) had normal anorectal results. Thirty-eight symptomatic women (8.4%) had an isolated abnormal EAUS result.

CONCLUSIONS

AM identifies more women with sphincter function impairment than EAUS alone. Without AM, almost one third of asymptomatic women would not have been identified and could have been inadequately counselled. Performing AM and EAUS together captured most women with compromised anal sphincter function. We conclude that AM should be performed in all women with OASI alongside EAUS to enable accurate MOB counselling.

Morphological differences in the female anal sphincter complex between endoanal and exoanal ultrasound

INTRODUCTION AND HYPOTHESIS

This study was aimed at describing the morphological characteristics of the normal female anal sphincter complex (ASC) by high-resolution transperineal ultrasound (TPUS) and endoanal ultrasound (EAUS).

METHODS

Thirty volunteers, including 19 nulliparous and 11 women who had only given birth by Cesarean section, were recruited. The ASC was shown in a set of five slices by EAUS and 8 slices by TPUS. EAUS slices 1 and 5 matched TPUS slices 1 and 8; EAUS slices 2, 3, and 4 were approximately at the levels of TPUS slices 3, 5, and 7. The anterior and lateral EAS and IAS thicknesses were measured and the two methods were compared.

RESULTS

The median age was 29 years. The mean body mass index (BMI) was 20.6 kg/m². All measured values obtained by TPUS were normally distributed. The EAS thickness on EAUS slice 2 and the IAS thickness on EAUS slices 2 and 3 were not normally distributed. The mean anterior EAS thickness was 2.51 mm, 2.96 mm, and 3.53 mm in slices 3, 5, and 7 on TPUS and was significantly thinner than that in slices 2 (2.62 mm), 3 (3.77 mm), and 4 (4.62 mm) on EAUS. In contrast, the IAS was markedly thicker on TPUS. The ratio of sphincter thickness anteriorly to laterally was similar using the two methods.

CONCLUSIONS

The morphological characteristics of EAS shown by TPUS and EAUS were similar. EAS was thinner, and IAS was thicker on TPUS. The IAS seems to be distorted on endoanal imaging.

An International Continence Society (ICS)/ International Urogynecological Association (IUGA) joint report on the terminology for the assessment and management of obstetric pelvic floor disorders

AIMS

The terminology of obstetric pelvic floor disorders should be defined and reported as part of a wider clinically oriented consensus.

METHODS

This Report combines the input of members of two International Organizations, the International Continence Society (ICS) and the International Urogynecological Association (IUGA). The process was supported by external referees. Appropriate clinical categories and a sub-classification were developed to give coding to definitions. An extensive process of 12 main rounds of internal and 2 rounds of external review was involved to exhaustively examine each definition, with decision-making by consensus.

RESULTS

A terminology report for obstetric pelvic floor disorders, encompassing 357 separate definitions, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it usable by different specialty groups and disciplines involved in the study and management of pregnancy, childbirth and female pelvic floor disorders. Clinical assessment, investigations, diagnosis, conservative and surgical treatments are major components. Illustrations have been included to supplement and clarify the text. Emerging concepts, in use in the literature and offering further research potential but requiring further validation, have been included as an Appendix. As with similar reports, interval (5-10 year) review is anticipated to maintain relevance of the document and ensure it remains as widely applicable as possible.

CONCLUSION

A consensus-based Terminology Report for obstetric pelvic floor disorders has been produced to support clinical practice and research.

Assessment of normal anal sphincter anatomy using transanal ultrasonography in healthy Korean volunteers

Background

To date, there have been no studies on the normal anatomic values of the anal sphincter in healthy Koreans. Therefore, this study aimed to determine the normal anatomic values of transanal ultrasonography (TAUS).

Methods

The thickness of the external anal sphincter (EAS) and internal anal sphincter (IAS) was measured by TAUS from healthy Korean volunteers between September 2019 and August 2021.

Results

Thirty-six volunteers with a median age of 37 years (range, 20–77 years) and a median body mass index (BMI) of 23.5 kg/m² (range, 17.2–31.2 kg/m²) were examined. The median thickness of the EAS at 4 cm and 2 cm from the anal verge was 7.4 mm (range, 5.8–8.8 mm) and 6.5 mm (range, 5.6–8.0 mm), respectively. The median thickness of the IAS at 2 cm from the anal verge was 1.8 mm (range, 0.8-4.3 mm). There were no differences in sphincter muscle thickness between the sexes. However, the EAS tended to thicken as the BMI increased (EAS at 2 cm and 4 cm from the anal verge, Spearman rho=0.433, 0.363; p=0.008 and p=0.029, respectively).

Conclusion

In healthy Korean, the median thickness of the IAS at 2 cm from the anal verge was 1.8 mm and the median thickness of the EAS at 2 cm and 4 cm from the anal verge was 6.5 mm and 7.4 mm respectively. There were no differences in anal sphincter thickness between sexes, but BMI was related to EAS thickness.

Establishing a peripartum perineal trauma clinic: a narrative review

INTRODUCTION AND HYPOTHESIS

Obstetric anal sphincter injury (OASI) is not rare, and its consequences are multiple and potentially severe, especially for young women. Some dedicated perineal clinics have been established to improve the management of OASI. Despite their obvious importance, these specific clinics are underrepresented and underdeveloped. The objectives of this review are to explore various options for developing a peripartum perineal clinic and to compare the different practices regarding the mode of delivery for subsequent pregnancies after an OASI.

METHODS

This narrative review covers information from patients' questionnaires specific to anal incontinence, anal physiology assessment, pelvic floor and anal sphincter imaging, and the arguments for choosing the mode of delivery after an OASI.

RESULTS

This review highlights the extensive range of practices regarding the delivery mode after an OASI throughout national professional organizations and experienced perineal clinics.

CONCLUSION

This review summarizes the different choices in developing a perineal clinic to facilitate their development in promoting health care and education specific for peripartum women concerning the perineal consequences of delivery for obstetrician-gynaecologists, family doctors, and residents.